A closed door opens: organ transplantation from brain dead donors.

Abstract

An organ transplant from a “brain dead” donor was performed after an interval of 31 years in Japan on February 1999. A woman possessing an “organ donation will card,” which allows organ donation under the condition of brain death as a prerequisite, was admitted to an emergency hospital because of brain disease. She had a diagnosis of brain death. Her heart, liver, kidneys, and corneas was transplanted into selected recipients. This was the first organ transplant from a brain dead donor in Japan since the Transplantation Law was passed in 1997. Since then, the second and third transplants were performed in May and June 1997, respectively. Before these cases, Japan was the only country among the advanced nations that had not permitted transplants from brain dead donors. Since the first case in South Africa in 1967, for example, heart transplants are now performed in as many as 4000 patients per year across the globe, but in only one patient before the current three in Japan. In Japan, whole brain death characterized by the disappearance of all brain activities is defined as human death. This criterion of brain death may reflect the deep impact of the first heart transplant performed in Japan in 1968. In this case, the transplant surgeon had evaluated the patient as brain dead. However, there were doubts about whether the patient (donor) was really brain dead and whether the recipient really required a transplant. Consequently, the attending doctor was prosecuted with murder. This heart transplant, which further deepened the distrust of the Japanese people concerning transplantation medicine, effectively closed the door to organ transplantation after brain death. As a result, the criteria for Japanese organ transplantation became extremely strict. Under such unfortunate circumstances, many lives that could have been saved by organ transplantation were lost. Because of the nonavailability of transplantation from brain dead donors in Japan, many Japanese patients have been forced to seek an organ transplant overseas. The estimated numbers of recipients who have undergone transplants overseas in 1997 are 38 for hearts, five for lungs, and <155 for livers (1). Therefore, these three cases of organ transplantation undoubtedly usher in a new epoch in Japan. However, this does not necessarily mean that the transplantation of organs from brain dead patients will become a routine therapeutic procedure immediately, because the organ transplantation law was not established after obtaining the full understanding of the Japanese people (2). A prerequisite for the prevalence of organ transplantation from a brain dead donor is the public’s understanding through the accumulation of cases in which brain death is accepted as “human death.” There are patients who can be saved only by organ transplantation. However, a more compelling fact is the willingness to donate organs after brain death. The essential missing link between brain death and organ transplantation, which are inherently independent matters, must be found. Kazuo Inoue1